| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
585 |
314 |
$27K |
| D1110 |
Prophylaxis - adult |
686 |
640 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
958 |
889 |
$20K |
| D0330 |
Panoramic radiographic image |
561 |
514 |
$17K |
| D0274 |
Bitewings - four radiographic images |
708 |
662 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
314 |
144 |
$11K |
| D1120 |
Prophylaxis - child |
215 |
203 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
84 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
325 |
299 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
116 |
55 |
$4K |
| D2394 |
|
60 |
26 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
570 |
511 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
86 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
115 |
110 |
$2K |
| D2330 |
|
40 |
13 |
$954.00 |
| D1999 |
|
281 |
223 |
$0.00 |